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©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
Body mass index and its association with clinical outcomes in acute liver failure
Arunkumar Krishnan, Sameer Khan, Julia Gips, Saleh A Alqahtani, Dhananjay Vaidya, Yi-Si Liu, Ahyoung Kim, Amanda Su, Ahmet Gurakar, James P Hamilton, Tinsay A Woreta
Arunkumar Krishnan, Saleh A Alqahtani, Ahyoung Kim, Amanda Su, Ahmet Gurakar, James P Hamilton, Tinsay A Woreta, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
Arunkumar Krishnan, Department of Supportive Oncology, Atrium Health Levine Cancer, Charlotte, NC 28204, United States
Arunkumar Krishnan, Department of Medicine, Wake Forest University School of Medicine, Winston Salem, NC 28204, United States
Sameer Khan, Julia Gips, Dhananjay Vaidya, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
Saleh A Alqahtani, Liver Transplant Center, King Faisal Specialist Hospital and Research Center, Riyadh 12713, Saudi Arabia
Yi-Si Liu, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21287, United States
Author contributions: Krishnan A performed the interpretation of data; Krishnan A and Khan S performed writing the original draft; Krishnan A, Khan S, Hamilton JP, Gurakar A, and Woreta TA revised the manuscript for important intellectual content; Krishnan A and Woreta TA conceptualized, designed, and drafted the methodology of the research; Krishnan A, Gips J, Kim A, and Su A performed data collection; Vaidya D and Liu YS performed the formal analysis; Woreta TA supervised the project; all authors reviewed, revised, and approved the final version of the article, including the authorship list.
Institutional review board statement: The study protocol was approved by the Institutional Review Board of the Johns Hopkins University School of Medicine, No. 00250968.
Informed consent statement: Informed consent was waived for a retrospective review of patient charts.
Conflict-of-interest statement: All the Authors have no conflict of interest related to the manuscript.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Tinsay A Woreta, MD, Assistant Professor, Division of Gastroentero
logy and Hepatology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Hal 407, Baltimore, MD 21287, United States.
tworeta1@jhmi.edu
Received: May 6, 2025
Revised: May 25, 2025
Accepted: August 12, 2025
Published online: October 26, 2025
Processing time: 161 Days and 20.9 Hours
BACKGROUND
Acute liver failure (ALF) is a life-threatening multisystemic condition with high short-term mortality. With the growing prevalence of obesity and metabolic syndrome, it is important to investigate the clinical implications of high body mass index (BMI) on survival outcomes in ALF.
AIM
To explore the impact of overweight and obesity on the clinical outcomes of patients with ALF.
METHODS
A retrospective observational cohort study was conducted involving patients with ALF admitted to the Johns Hopkins Health System between January 1, 2000 and May 1, 2020. We performed Cox proportional hazards regression to identify outcomes, including the need for liver transplantation (LT) or all-cause mortality.
RESULTS
A total of 196 patients were included, the median age was 43.5 years, 63.3% were female, and 59.7% were of Caucasian ethnicity. Acetaminophen-induced ALF was the most common etiology (45%). The mean BMI was significantly greater among patients who underwent LT or died (29.64 kg/m2vs 26.59 kg/m2, P = 0.008) than among survivors. Patients with overweight and obesity had a higher risk of all-cause mortality or need for LT by 2.22-fold (95%CI: 1.30-3.78) and 2.04-fold (95%CI: 1.29-3.39), respectively. Elevated BMI was associated with renal failure and higher grades of hepatic encephalopathy. Derangements in serologic markers, including alanine transaminase, lactate, and ammonia, were associated with a mortality risk or need for LT.
CONCLUSION
In this large, retrospective study, with a diverse cohort of United States patients, Overweight and obese were independently associated with an increased risk of all-cause mortality or need for LT. This work highlights the importance of closely monitoring ALF patients who are overweight or obese for adverse complications and measures to improve outcomes in this vulnerable patient population.
Core Tip: The most common causes of acute liver failure (ALF) were acetaminophen toxicity, drug-related hepatitis, and other etiologies. Patients who underwent liver transplantation (LT) or died were older, had a higher body mass index (BMI), and were more likely to have higher-grade hepatic encephalopathy and cerebral edema. They also had higher levels of lactate and phosphate. Overweight and obese patients with ALF had a higher risk of mortality or the need for LT than normal-weight patients. Factors such as increasing age, other etiologies of ALF, higher BMI, and abnormal laboratory values were associated with an increased risk of poor outcomes in ALF patients.
